Ways to Assess Medication Adherence…in Practice
Transcript of Ways to Assess Medication Adherence…in Practice
Karen B. Farris, PhD, Charles R. Walgreen III
Professor of Pharmacy Administration
Chair, Department of Clinical Pharmacy
University of Michigan College of Pharmacy
Ways to Assess Medication
Adherence…in Practice
Disclosures
• Submission of an SBIR grant to NIH with
iRx Reminder.
• Using MEMS© caps in an AHRQ-funded
artificial-intelligence guided text
messaging intervention study (R21-HS-
022336-01A1).
Objectives
1. Describe a model of medication
adherence and persistence.
2. Explain different ways to assess
medication adherence.
3. Understand why asking about reasons
for medication non-adherence for each
medication/class is necessary.
Positive Short-term Results
Health status Treatment satisfaction
Medication adherence Medication
Beliefs
Disease Beliefs
Intention Remember
Strategies, Cues
Model System of Medication Adherence and Persistence
Capacity
Executive function Psychomotor ability Skill
Availability
Cost Shortages
Long-term Outcomes
Reduced morbidity Improved quality of life
Coping Strategies e.g. Social Support,
Other medications, CBT, exercise
Negative Short-term Results
ADE Side effects
Medication persistence
Facts
1. Medication non-adherence is prevalent.
2. Medication non-adherence leads to poorer
outcomes and higher costs.
3. Medication non-adherence is a decision and is
caused by numerous, varying reasons.
4. The same individual can be adherent to one
medication and not to another.
5. Medication non-adherence is experiencing an
increased visibility among payers and policy-
makers.
Fiction
1. There is a non-adherent persona or personality.
2. People should just do what their doctors say.
3. It’s only about whether people can afford their medicines.
4. We know how to improve medication non-adherence.
Methods of Measuring Adherence
• Direct
– Directly observed therapy, e.g., TB, mental
health facilities
– Blood level, e.g., warfarin
Methods of Measuring Adherence
• Indirect
– Real-time bottle technology
– Electronic pill caps (download periodically)
– Refill rates, e.g, PDC, MPR
– Pill counts, e.g., in-person or phone-based
– Therapeutic response
– Self-report, e.g., questionnaire or diary
– Proxy report, e.g., parent or caregiver
Electronic monitoring ...
Electronic monitoring…
What is practical in day-to-day
practice?
What is practical to assess medication non-adherence?
• Blood level
• Refill records
• Self-report
• ? Unannounced pill count (can be telephonic)
• ? Electronic monitoring
Quick, valid adherence
assessments you may use in
practice…and you must follow-up
with Reasons
1. Single-item past 7 days
2. Single-item rating scale (SIRS)
3. DRAW©
Single item past 7 days (Unni, Olson & Farris, 2013)
• Over the last 7 days, how many days were you able to take your [specific medicine] exactly as prescribed? ☐ 0 days
☐ 1 day
☐ 2 days
☐ 3 days
☐ 4 days
☐ 5 days
☐ 6 days
☐ 7 days
Single Item Rating Scale (Feldman, et al,
AIDS Behav 2013)
• Thinking about the past 4 weeks, please rate your ability to take your [insert medication name] as prescribed.
___Excellent
___Very good
___Good
___Fair
___Poor
Doucette, Farris, Youland,
et al, JAPhA, 2012; Witry,
et al JMCP 2014
Reasons for non-adherence (Unni & Farris, 2009; 2011; Unni, Olson & Farris, 2013)
We know there are many reasons why people miss their medications. In thinking about your [name of drug], please check all the reasons that caused you to miss it during the past 4 weeks. ___I experienced side effects from it.
___I have concerns about possible side effects from it.
___I have concerns about long term effects from it.
___I do not think I need it anymore.
___I do not think that it is working for me.
___I did not have the money to pay for it.
___The pharmacy did not have it or could not get it.
___I have trouble managing all the medicines I take.
___I have trouble take it because of how and when I have to take it.
___I missed it because of my busy schedule.
___I have trouble forgetting things in my daily life.
___I simply missed it.
___Other _________________________________
Did not ask about forgetting…
• I would have taken it but…
– Simply missed it
– Busy schedule
– Have problems forgetting things in my life
– Did not consider taking medication a high
priority
Some data…
Comparisons…
• Cholesterol lowering medications
– 50% non-adherent using reasons
– 37.4% using single item past 7 days
– 30% using Morisky
• Asthma maintenance medications
– 68% non-adherent using reasons
– 44% using single item past 7 days
– 62% using Morisky
Excellent 82%
Very Good 8%
Good 6%
Fair 1%
Poor 3%
Inthepast4weeks,self-ratedabilitytotakeAImedica on(n=226)
Excellent 74%
Very Good 17%
Good 8%
Fair 1%
Inthepast4weeks,self-ratedabilitytotakeoraloncoly cmedica on(n=117)
Lu et al, AIDS Behav 2008, (See also Feldman, AIDS Behav 20130
Frequency of reasons for non-adherence to asthma maintenance medicines… (Unni & Farris, 2009; Unni & Farris 2011; Unni, Olson & Farris, 2013)
Frequency of reasons for non-adherence to cholesterol-lowering medicines… (Unni, Olson & Farris, 2011)
Reasons, where adherence <90% 0 days (%)
1-2 days (%)
3 or more
days (%)
I don’t have the medicine because the pharmacy is out 89.9 8.1 2
I am concerned about possible side effects from this medicine 88.7 3.3 8
I had side effects from this medicine 88 5.3 6.7
I am concerned about the long-term effects from this medicine 88 2.6 9.4
I do not have the money to pay for this medicine 84.7 7.4 7.9
I would have taken it but have problems forgetting things in
my daily life 83.3 12.7 4
I would have taken it but simply missed it 72 22 6
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
HadSideEffects
Cost
NotNeeded
ConcernedAboutSide
LongTermEffects
PharmacyOut
MissedtakingM
ed
Missedbecausebusy
ForgeulinDailyLife
Other
ReasonsfornottakingAImedica on
Witry, et al, JMCP, 2014
Conclusions
• It is more prevalent that you might think
• Different reasons for different medications
• Use a single item, refill records or clinical indicators to gain insight, then ask about reasons
• Reasons interventions…asking about reasons will give you more information about frequency and cause
Objectives
1. Describe a model of medication
adherence and persistence.
2. Explain different ways to assess
medication adherence.
3. Understand why asking about reasons
for medication non-adherence for each
medication/class is necessary.